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Why Multiple Chronic Diseases? Why now? What is going on around the world?

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Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: The price of success
 
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The price of success

“In this fallen world everything good has unintended evil consequences, every Yang has a Yin"(1).

In 2004, two scholars announced that they had discovered the earliest known version of a poem by Sappho, the Greek poetess known as the Tenth Muse (2). It was written on a fragment of a papyrus used to cover an Egyptian mummy kept at the University of Cologne, in Germany. The poem, which had been transcribed at least 300 years after the death of Sappho, became one of the most complete examples of her work available to date.

The poem is a compact masterpiece. In just 12 lines, it captures the poetess’s insights into her own ageing process and the plight of humans as we grow old. Her words, which resonate more than ever 2700 years later, read as follows (those in brackets were missing from the fragment, and were filled in by the translator (3)):

"[You for] the fragrant-blossomed Muses’ lovely gifts

[be zealous,] girls, [and the] clear melodious lyre:

 

[but my once tender] body old age now

[has seized;] my hair’s turned [white] instead of dark;

 

my heart’s grown heavy, my knees will not support me,

that once on a time were fleet for the dance as fawns.

 

This state I oft bemoan; but what’s to do?

Not to grow old, being human, there’s no way.


Tithonus once, the tale was, rose-armed Dawn,

love-smitten, carried off to the world’s end,

 

handsome and young then, yet in time grey age

o’ertook him, husband of immortal wife."

 

In the last four lines, Sappho refers to a myth that was very popular in the 7th century BCE as a means to convey the suffering associated with the decay of human bodies, as they age.

According to this story, the Goddess of the Dawn, Eos, had fallen in love with Tithonus, a Trojan. As she could not conceive of a life without her mortal lover, Eos persuaded Zeus to grant Tithonus eternal life. Zeus, however, took Eos’s request literally. He made Tithonous immortal, but did not give him eternal youth. As a result, Tithonus started to grow old, becoming progressively debilitated by multiple chronic conditions and
demented. The myth ends with Eos trying to mitigate Tithonus’s suffering by transforming him into a grasshopper.

At the dawn of the 21st century, millions of people around the world are facing the same challenges illustrated in the myth of Tithonus and in Sappho’s poem. The extraordinary level of control of acute conditions and the lengthening of life expectancy achieved by humans in the 20th century is now ushering in a global epidemic of chronic diseases and infirmity.

The high prevalence of chronic conditions is already having a major effect on mortality data across the world. In a landmark report entitled Preventing Chronic Diseases: a landmark investment, the World Health Organization (WHO) estimated that 60% of deaths around the world in 2005 were already due to chronic diseases, with 80% of the total occurring in low- to middle-income countries ( 4). In fact, chronic diseases are the leading cause of death in every country in the world, except for those with the lowest levels of income. Even in the latter, however, the gap separating them from infectious diseases is narrowing (5). To compound this, depression and not physical injury, is now the leading cause of years lost to disability in the world (6).

Sadly this epidemic, which has been the subject of many recent reports ( 7), is being underestimated and neglected ( 8).

Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: The emergence of polypathology
 
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The emergence of polypathology

The high prevalence of chronic diseases has created yet another new phenomenon: a growing number of people are living with multiple chronic diseases.

This phenomenon includes not only those individuals with an index disease that has triggered secondary conditions (e.g., a person with diabetes who is affected by associated retinopathy and neuropathy), but also those in whom two or more diseases co-exist (e.g., people with diabetes, cancer and Alzheimer’s disease at the same time).

As will be discussed in more detail in the next chapter, there is no accepted terminology for this phenomenon. The labels that seem to be used most frequently seem to be «comorbidity», «polypathology», «poly-pathology», «pluripathology», «pluri-pathology», «multi-morbidity», «multimorbidity», «multi-pathology» or «multipathology» or «complex chronic disease» (Chapter 2). Polypathology will be the term used most often throughout this chapter.

Just like the fragments of Sappho’s poems, however, there appears to be a patchy picture of knowledge on the prevalence of polypathology and its associated societal burden. Most reports provide data on specific disease clusters, in high risk groups, or in specific regions or countries ( 9). Very few, if any, seem to contain original data on the prevalence of several diseases, detected and documented simultaneously, across all age groups, worldwide.

A refined search of MEDLINE conducted on April 14, 2009 (Figure 1), complemented by a search of Google and Google Scholar on August 22, 2009, revealed a few glimpses of what may be happening.

 

Figure 1. Search strategy

fig1

Database: Ovid MEDLINE(R) <1950 to April Week 1 2009>.

Source: U.S. National Library of Medicine. Ovid Medline [Web site]. [access April 1st, 2009]. Available at:http://ovidsp.tx.ovid.com/

One of the main messages from the patchy literature is that the estimates of the prevalence of polypathology among adult members of the general public vary widely, with figures ranging from 17% to just over 50% (10- 13).

A more consistent finding is that people with polypathology may represent 50% or more of the population living with chronic diseases, at least in high-income countries. For instance, a systematic review of 25 Australian studies conducted from 1996 to 2007 found that half of the included elderly patients with arthritis also had hypertension, 20% had cardiovascular disease (CVD), 14% diabetes and 12% a mental health condition.Similarly, over 60% of patients with asthma reported living with arthritis, 20% CVD and 16% diabetes; and of those with CVD, 60% also had arthritis, 20% diabetes and 10% had asthma or mental health problems ( 14). A study of a random sample of 1,217,103 patients from the United States who had been receiving Medicare services for over a year (and so were 65 or older) showed that two thirds (65%) had multiple chronic conditions ( 15). Studies of patients admitted to hospitals in Spain also show a prevalence of polypathology ranging from 42% to just over 57% (16,17).

Data from other studies show even higher prevalence levels among people living with specific chronic diseases. An analysis of five randomly selected clinical trials that included patients with hypertension in Canada in 2003 revealed that 89% to 100% had multiple chronic conditions with a mean number of chronic conditions that ranged from 5.5 to 11.7 ( 18). A similar pattern was found among people living with chronic obstructive pulmonary disease as their index condition in Italy, where 98% of participants in a large cohort of patients had been prescribed at least one non-respiratory drug. The coexisting disease was cardiovascular in 64% of cases, diabetes in 12% and depression in 8% (19). A prevalence of polypathology of 91% was also found in a sample of indigent, predominantly African-American patients in the United States ( 20).

As expected, the prevalence of polypathology seems to progress with age. An assessment of two large Australian national surveys conducted in 2001 and 2003 showed that the proportion of people who live with three or more chronic conditions increased from 34% for those members of the general public with ages between 20 and 39 years, through 57% between 40 and 59 years, to 80% between 60 and 74 years, and 86% at 75 years or more (12).

It is difficult to determine the proportion of people living with different numbers of coexisting diseases not only because of the scarcity of studies, but because of the use of different metrics across those available. A Danish analysis of data gathered over two decades suggested that four or more diseases were present in 7% of people with ages between 45 and 64 years, increasing to 30% between 65 and 74 years and to 55% among those 75 years and older ( 21). Analyses of Medicare beneficiaries have shown that 23% live with five or more diseases (22). In Spain, it was estimated that people with ages between 65 and 74 years had a mean of 2.8 chronic conditions, while those over the age of 75 had 3.2 diseases on average ( 23). A French study of 100 patients aged 80 and over who were hospitalized in a geriatric unit showed that the mean number of recognized diseases per patient was 4.1 (range 1-10) ( 24).

In addition to older age, multivariate analyses have found that obesity, being female with low socioeconomic status, and living alone are associated with a significantly greater probability of having three or more chronic illnesses (12). In addition to the association with gender and older age, another study showed an increased risk of polypathology among people with low levels of education, with health insurance and those living in a home for the elderly (10).

Data on the mortality rates by number of chronic diseases in people with polypathology are also limited. A study of individuals aged between 55 and 64 years that used Veterans Health Administration health care services between October 1999 and September 2000 showed a 5-year mortality rate that increased from 8% among people with two conditions, through 11% for those with three, to 17% for those with four or more (25 ).

Data on polypathology from low- and middle-income countries are sparse also. In a study of 844 patients with heart failure who attended a hospital in Soweto, South Africa, 172 (24%) also had renal dysfunction, 83 (10%) coronary artery disease, 18 (2%) a history of acute myocardial infarction, 86 (10%) diabetes, 72 (10%) anemia, 58 (7%) stroke, and 53 (6%) atrial fibrillation (26). A survey of households substantially affected by serious illness in two counties in China identified 2,259 people with chronic disease, of whom 2,140 (95%) had one condition, 110 (5%) two, and 9 (0.4%) three (personal communication) (27).

Only one of the identified studies provided data on the prevalence among children or adolescents. This effort, which used data from the Registration Network Family Practices in The Netherlands, showed that 10% of people from birth to 19 years of age are likely to have multiple chronic diseases (10).

The high prevalence of chronic diseases has created yet another new phenomenon: a
growing number of people are living with multiple chronic diseases.
This phenomenon includes not only those individuals with an index disease that has
triggered secondary conditions (e.g., a person with diabetes who is affected by associated
retinopathy and neuropathy), but also those in whom two or more diseases co-exist (e.g.,
people with diabetes, cancer and Alzheimer’s disease at the same time).
As will be discussed in more detail in the next chapter, there is no accepted terminology
for this phenomenon. The labels that seem to be used most frequently seem to be «comorbidity
», «polypathology», «poly-pathology», «pluripathology», «pluri-pathology»,
«multi-morbidity», «multimorbidity», «multi-pathology» or «multipathology» or
«complex chronic disease» (Chapter 2). Polypathology will be the term used most
often throughout this chapter.
Just like the fragments of Sappho’s poems, however, there appears to be a patchy
picture of knowledge on the prevalence of polypathology and its associated societal
burden. Most reports provide data on specific disease clusters, in high risk groups, or
in specific regions or countries (9). Very few, if any, seem to contain original data on the
prevalence of several diseases, detected and documented simultaneously, across all
age groups, worldwide.
A refined search of MEDLINE conducted on April 14, 2009 (Figure 1), complemented by
a search of Google and Google Scholar on August 22, 2009, revealed a few glimpses of
what may be happening.
Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: Why this book now?
 
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Why this book now?

Our limited knowledge about polypathology is not only restricted to an understanding of its prevalence. In 2006, the Veterans Health Administration (VHA) in the United States organized a conference entitled Managing Complexity in Chronic Care, motivated by the risk of having insufficient funds to meet the health service needs of its target population (e.g., war veterans, active service members in time of war and people affected by national emergencies). This concern was fueled by the realization that 96% of Medicare expenditure at that time was already being directed to people living with multiple chronic diseases (28).

The insights generated before, during and after this event were published as nine short articles in a special supplement of the Journal of General Internal Medicine in December of 2007( 29). An accompanying overview listed nine key research topics that had been identified as a result of the deliberations of the participants about unmet care needs for people living with multiple chronic diseases (Figure 2).

Figure 2. Research topics in the management of patients with complex chronic care needs identified at the SOTA conference sponsored by the VHA in 2006 (28)

 

2chapter1

Completely unaware of the unfolding VHA efforts, leaders at the Andalusian Ministry of Health in Spain also identified the growing prevalence and burden of complex chronic diseases among its target population, making it a top priority for action. As they had supported a long collaborative effort to develop, implement and evaluate a care process to optimize the management of polypathology, at all levels of their regional health system, they were fully aware of the slowly growing interest in this topic in other parts of the world. They were also conscious of the almost complete absence of meaningful collaboration among leading groups. They recognized that most of the available work had evolved in isolated pockets, missing important opportunities for effective collective learning and for the creation of the large-scale joint efforts required to meet the needs of those living with multiple chronic diseases.

Back in 2006, there was no single place, physical or digital, in which interested people could collaborate across traditional institutional, geographic, professional, linguistic, political, disciplinary and cultural boundaries, to face the challenges created by polypathology.

Against this background, and encouraged by the rapid development and penetration of powerful online resources for collaboration (e.g., wikis, social networking tools), the Andalusian Ministry of Health decided to promote the creation of a global observatory designed to promote the exchange of knowledge and joint efforts among individuals and organizations interested in the management of complex chronic diseases, anywhere in the world.

The Observatory, which is known as OPIMEC (the Spanish acronym for Observatory of Innovative Practices for Complex Chronic Disease Management), is available in English and Spanish at www.opimec.org. In essence, it is a collaborative virtual environment that uses state-of-the-art tools to allow health professionals, researchers, policy-makers and the general public to:

- Access and contribute to the development of a common language with which to improve communication about poly-pathologies across traditional boundaries (supported by wikis).

- Identify, classify, suggest and adopt innovative practices that could improve quality of care in their own settings (supported by Google Maps).

- Communicate and collaborate with individuals who share an interest in meeting the challenges associated with polypathology (supported by online social networking tools).

In mid-2008, the members of the International Advisory Committee of OPIMEC, a group of leading experts in chronic disease management from North America, Europe and Australasia, suggested that the Observatory focus specifically on polypathology, as thiswas regarded not only as neglected, but also as a source of important opportunities for «glocal» impact (global and local, at the same time).

In March 2009, the Andalusian Ministry of Health convened a meeting in Seville of its keyregional leaders in the management of chronic diseases and their closest collaborators from other regions of Spain and around the world. Together, the participants identified ten poorly-understood areas related to polypathology that they felt could benefit from international collaborative initiatives:

- Epidemiological issues.

- The language of polypathology and assessment of complexity.

- Prevention and health promotion.

- Disease management models.

- Patient education and self-management.

- Primary care and integrated management processes.

- Supportive and palliative care.

- Demedicalization of care (with emphasis on complementary and alternative interventions).

- Economic, social and political implications.

- The Promise of Genomics, Robotics, Informatics/eHealth and Nanotechnologies (GRIN).

Collectively, the event participants expressed strong interest in using OPIMEC to codevelop and share a body of constantly evolving knowledge that could be made available to anyone, anywhere in the world, at any time, in digital form and free of charge. As a catalyst for this ambitious global collaborative effort, the group decided to produce a book, in digital and paper form, in English and Spanish, which could be launched during Spain’s presidency of the European Union in the first half of 2010, and made available to anyone interested, free of charge.

Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: The approach
 
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The approach

During the March 2009 meeting, participants were invited to lead (main) or identify lead contributors for specific book chapters focused on each of the neglected areas that they had identified.

By the end of the month, all chapters had been assigned to a lead contributor who had committed to having the first draft ready by the summer of 2009. At that point, the initial senior editorial group had also been confirmed (Dr. Lyons joined the editorial group at the end of the year), and a technical support team and a roster of potential contributors had been established.

All of the lead contributors agreed to follow a series of principles to ensure maximum transparency to future audiences, and to prevent any unnecessary perception of conflicts of interest or bias. They:

- Used language that would be accessible to different potential audiences, including policy-makers, clinicians, managers and researchers. A lay summary would make the essence of each chapter easy to grasp for the general public.

- Disclosed their affiliation with organizations that may have an interest in the management of poly-pathologies in general, or with a specific topic in particular.

- Made explicit any personal or organizational biases that may influence the tone and emphasis given to the topic being addressed.

- Avoided over-emphasizing or focusing just on issues that related to their professional activities or organizational goals, be they political, financial or academic.

- Acknowledged, whenever possible, the work of individuals and organizations with opposing views or with competing interests.

- Made their contributions without financial or political incentives.

The contributors also agreed to follow a structured format for each of the chapters, with the following sections:

- A vignette outlining a vision of the future using a 20- to 30-year horizon.

- A brief summary highlighting the main points covered in the rest of the chapter, using language that could be understood by any interested reader.

- Why is the topic important? This section described the magnitude of the challenge associated with this specific topic, providing as much data as possible, including all regions in the world, while trying to address the perspectives of different groups of stakeholders (patients and their caregivers, policy-makers, managers, funders and academics).

- What do we know? Here, contributors summarized the research literature available on the topic, highlighting the implications for each of the above groups of stakeholders. In each chapter, contributors ensured that they had drawn from the initial literature search, as well as from their own collections of resources.

- What do we need to know? This section emphasized the knowledge gaps that exist around this topic, and why it would be important to fill them.

- What innovative strategies could fill the gap? The contributors ended each chapter with proposed innovative efforts that could be pursued to fill the identified gaps, focusing on methodological issues, resource needs (technological, financial and human) and the role that OPIMEC could play in the process.

Six of the chapters were produced initially in Spanish and four in English (those that dealt with epidemiological issues, prevention and health promotion, supportive and palliative care, and demedicalization of care).

One of the senior editors (FM) supported contributors writing in Spanish and another (AJ) those working in English. The latter, fluent in both languages, was responsible for reviewing all of the initial drafts, for harmonizing their content, eliminating redundant content, and identifying areas for improvement.

The revised draft chapters, with suggested changes, were sent to each of the lead contributors, who in turn produced refined versions. In most cases, two iterations of revisions were completed before the initial drafts were considered to be ready for translation.

Once each of the drafts had been translated to the alternate language, the same bilingual senior editor (AJ) reviewed them for accuracy and, whenever appropriate, edited the content further, in both languages.

The translated files were then sent to the respective lead contributors for verification and approval. Once approved by them, the draft chapters were uploaded to the OPIMEC platform by the support team, in a format that included separate interactive sections designed to allow readers to make comments and suggestions for improvement (Figure 3).

 Figure 3. Interactive table of contents with a section sample

 Fig3_en

 Source: OPIMEC. [Web site]. [access May 5th, 2010]. Available at: http://www.opimec.org 

While the chapters were being uploaded, the editors and lead contributors produced a list of peers they felt could provide useful comments on each of the drafts, selecting them from among colleagues they knew or the authors of key articles they had used as references. The editors then sent an electronic message to the members of this list, inviting them to read the chapters and make comments, either anonymously or by registering as members of the OPIMEC community. In all cases, the support team was available to provide technical assistance under supervision by one of the editors (AC).

Throughout the process, the terms contributor and contributorship were considered to be more consistent with modern approaches to acknowledging the work of members of collaborative groups than the more traditional author or authorship (30).

A minimum of a month after the chapters were uploaded to the platform, the editors reviewed all of the comments received and produced lists of substantive changes that were sent to the lead contributors for incorporation into the drafts.

The revised versions were then reviewed thoroughly by the editors (RS, RL and AJ in English, and PM, AC and AJ in Spanish), who could make modifications to the main text online. Those individuals who made substantive comments, as judged by the editors by consensus, were recognized as book contributors.
Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: The output
 
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The output

By the end of February of 2010, less than a year after the original meeting in Seville, the chapters that we present in this book had been completed, revised in draft form at least twice, and approved by the editors. The eleventh chapter was added soon before the submission of the final version of the paper edition of the book in April 2010.

Contributions were received from individuals living in all of the inhabited continents. Most of them, however, were made by colleagues who were approached at the outset by the editors and by members of their immediate teams or circles of collaborators.

Despite their ease of use and the availability of technical support at all times, some contributors preferred to use traditional electronic mail to produce content over the online resources available on the OPIMEC platform. This made the editing process difficult at times, as contributors would send different versions of their work directly to individual editors, creating unnecessary confusion and duplication of effort.

The editors, on the other hand, communicated mostly by electronic mail, complementing their frequent (at least weekly) text-based interactions with online videoconferences and in-person meetings whenever possible.

The conversion of the contributions into homogeneous versions in English and Spanish was not a straightforward process. The translations, which were mostly precise reflections of the original text, required heavy editing to make them flow as comfortably as possible for readers in the alternate language. This led to inevitable mismatches between the versions, which bilingual readers will recognize easily in most cases.

Another interesting aspect of this effort was the process to decide when to consider the digital content that was emerging through such a diverse collective of contributors to be ready for publication in book form. In most cases, the threshold was determined by the absence of comments from existing or new contributors. In the remaining few, the editors had to decide, by consensus, that the chapter was good enough for release in static form. Continued revision of these few chapters was not possible because ofthe limitations imposed by the publishing timelines and the need to launch the content as a paper-based book in early June 2010. Nevertheless, having the entire contents available online, through the OPIMEC platform, should enable any interested reader to make suggestions as to how to improve on what has been produced so far.

In any case, the book achieved its original overarching objective: to act as a powerful stimulus for collective effort, across traditional boundaries, among people interested in improving the management of complex chronic diseases. Without the incentive associated with the creation of something so tangible, or the pressure generated by publication deadlines and launch dates, it would have been difficult to achieve so much, in so short a period of time, and with no financial incentives. Along the way, those who responded made a substantial and generous attempt to summarize the limited knowledge available around this important and seriously neglected area, while proposing innovative strategies to fill the gap between what is known and what should be done to meet the needs and expectations of a growing number of vulnerable people in every society in the world.

Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: Contributors
 
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Contributors

Alejandro Jadad wrote the first draft of this chapter in English and approved its Spanish translation. All of the other editors (Andrés Cabrera, Francisco Martos, Renée F. Lyons and Richard Smith) reviewed the chapter and approved it, with minor comments. These, together with valuable contributions from Kerry Kuluski, were incorporated by AJ into the final version that was included in the paper-based book.


Responsibility for the content rests with the contributors and does not necessarily represent the views of Junta de Andalucía or any other organization participating in this effort.

Acknowledgments


Joseph Ana, José Miguel Morales Asencio, Bob Bernstein, Murray Enkin, John Gilles, Marina Gómez-Arcas, Rodrigo Gutiérrez, Jacqueline Ponzo and Ross Upshur made insightful comments on the chapter that did not lead to changes to its contents. Such comments, which were greatly appreciated, were considered for inclusion in other chapters of the book.

How to reference


Jadad AR*, Cabrera A, Martos F, Smith R, Lyons RF. [*Main contributor] Why Multiple Chronic Diseases? Why now? What is going on around the world?. In: Jadad AR, Cabrera A, Martos F, Smith R, Lyons RF. When people live with multiple chronic diseases: a collaborative approach to an emerging global challenge. Granada: Andalusian School of Public Health; 2010. Available at: http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases  

Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: References (click here to access)
 
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Are you sure you want to delete this section?Why Multiple Chronic Diseases? Why now? What is going on around the world?: Creative Commons License
 
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Creative Commons License

Creative Commons License

Why Multiple Chronic
Diseases? Why now? What is going on around the world? by Jadad AR, Cabrera A, Martos F, Lyons RF and Smith R is licensed under a Creative Commons Reconocimiento-No comercial-Sin obras derivadas 3.0 España License.

 

Comments to the whole document Comments feed

Kath · 18/11/2010 05:43

I write as a carer and wish to comment on the poor treatment of patients with polypathology from the viewpoint of 'what are the reasons the medical profession provide such inadequate care to this group of patients'?. One reason is that it is just too hard a challenge to take on. Much better to have a patient with appendicitus or a broken leg. The 'cure' for the ailment is apparent, the patient can be 'fixed' and the Doctor can feel good about themselves. They achieved what they were trained to do - fix people. With patients with polypathology they are hard to 'fix' and certainly the fix when applied may be inadequate or shortlived. This makes the Doctor feel bad, they feel they have failed . People don't like to fail so they avoid failure. The way they do this is to 'avoid' the patient - sometimes avoiding can be active ( fobbing off with treatment that won't work) as well as passive e.g longer periods between appointments.

Another aspect is that Doctors are becoming more and more specialised in their chosen field and therefore less holistic in their approach. From the patients point of view this can result in prescribing conflicting medication, prescribing medication the patient shouldn't take, prescribing medication or treatment which makes one aspect of the patients condition better whilst making another worse. The carer or patient  must then act as gatekeeper often 'managing a team' of 6 - 9 consultants who seem incapable of working as a team either by attitude or by the fact that they work in different hospitals, records are not shared and so on.

 

Juan Manuel Alvarez Gutiérrez · 25/12/2010 09:20

Pues a mí este documento me trae a la memoria el problema de la polimedicación y creo que no aparece demasiado remarcado en el texto preliminar por lo que opino que debería incorporarse en alguna parte; Hay que concienciar al enfermo y al médico que los medicamentos no están exentos de riesgos. Se deben pautar cuando existe una clara indicación, y una vez cumplida su misión deben retirarse, sólo de esta forma se logrará disminuir la incidencia de este problema en nuestro medio. Todo médico, y más en Atención Primaria, debe tener una visión global del paciente para adecuar la prescripción a las características individuales del enfermo.

El paciente anciano polimedicado:

efectos sobre su salud y sobre

el sistema sanitario

Ter Sist Nac Salud 2005; 29: 152-162. 

Blasco Patiño F1

 

Martínez López de Letona J2

 

Villares P3

Jiménez AI4

jaedma58
Jaime Mazal
04/05/2011 15:19

Me parece que el comentario de Juan Manuel Alvarez Gutierrez sobre la polimedicación es muy acertado y oportuno. En mi caso particular en la ciudad de Córdoba, República Argentina, dirijo un Programa de Adultos Frágiles, uno de los capítulos complejos y de mayor vulnerabilidad de estos pacientes es la polimedicación, donde los médicos tenemos la responsabilidad de "praxis" científica, pero ademas la docencia con el paciente explicando los riesgos del uso y abuso de los fármacos. Esto en el marco del "autocuidado" de la salud promovido desde la APS y es en lo que hacemos hincapié en nuestro programa 

vquiroga
Victoria Quiroga
11/01/2012 20:53

Estoy totalmente de acuerdo con la opinion de los dr Kath, Alvarez y Mazal. No solo exite el problema de la pluripatologia, ya de por si complicada, si no que a esto se le suma el problema de las pluriespecialidades y de la polimedicacion, con lo cual los pacientes lo perciben todo como muy caotico ( informacion no concordante, lista interminable de medicamentos, pruebas complementarias duplicadas... ) ;en medio esta el medico de atencion primaria que muchas veces se ve desbordado en como trasmitir un plan comun , que sea facil de asumir por los  enfermos y cuidaores ( si es que se dejan....el especialista hospitalario sigue siendo "el especialista" en nuestra cultura )

Raimundo
Raimundo Tirado Miranda
04/04/2012 14:04

En general los distintos capítulos hacen un repaso de nuestra práctica clínica diaria, la menos de los profesionales que se encuentran sensibilizados con el problema de la polipatología y la sostenibilidad del sistema.

A mi me interese destacar dos puntos fundamentales para los objetivos mencionados anteriromente:

1.- el avance en la autonomía de gestión del paciente de su propio estado de salud, es decir, del compromiso de los pacientes con sus cuidados y con las indicaciones emanadas desde los profesionales de la salud sin el cual es imposible avanzar en mejorar objetivos de salud. ES más, creo que debe se objeto de política sanitaria aunque no sabrías especificar que estrategias serían las más adecuadas.

2.- La importancia de adaptar las posibles soluciones a nuestro ámbito de trabajo, bien inovando o bien incorporando experiencias exitosas de otras profesionales siempre que sean factibles en nuestro medio. Es este sentido, el proyecto Gerendia me parece acertado.

 

antoniopinto
Antonio Gonzalez Pinto
13/05/2012 11:31

Parece que esta claro que el aumento de años de vida lleva aparejado un aumento  de patologias crónicas y  dolencias y que a estas tenemos que sumar el aumento de depresion.

Me llama la atencion el comentario que nos informa que el aumento de esta polipatologias se da con mas frecuencia en personas con renta baja, con sistema sanitario publico y residentes en residencias de mayores.

si todo esto es asi,

- no deberiamos cambiar nuestra vision del proceso de envejecimiento y abarcarlo desde otro punto de vista??

- no deberiamos estudiar que tipo de usuarios tenemos en nuestras residencias de ancianos y desde aqui cambiar tambien nuestra atencion??

 

ftalledop
Federico Talledo Pelayo
13/05/2012 12:26

Es llamativo que la mayoría de los estudios publicados sean realizados desde el análisis parcial del estudio de patologías estudiadas en centros hospitalarios, donde la revisión de la información de los pacientes es muy laboriosa al no estar informatizada.

Una fuente muy importante de información la existente en Atención primaria donde la información esta informatizada desde hace muchos años, con unos criterios diagnosticos reglados por los programas informaticos que se usan y clasificadas las patologías con la Clasificación Internacional de Atención Primaria (CIAP), con una correlación con la CIE. Además permite tener una información longitudinal frente a los cortes que se pueden realziar en las visitas a los centros hospitalarios o en consultas externas. La información que se obtiene de la mediciación también es muy completa. La no utilización de estos recursos, por lo menos nos debe plantearnos una serie de reflexiones, por lo menos en Atención Primaria:

  • ¿están los profesionales que trabajan en atención primariua en la cronicidad, multipatología y la polimedicación?
  • ¿Las políticas estratégicas exustentes abordan estos temas?
  • ¿Por qué no se quieren usar estos datos en los análisis?
  • ¿Por que no se hace un abordaje integral de la salud de nuestros pacientes, siendo diferente de cada lugar de trabajo?

quizas por medio de estos capítulos y su difusión sean cada vez más los profesioanles que se interesen por este tema y podamos aprender de las experiencias que ya están en funcionamiento.

 

soniasc
Sonia Sancho Cabrera
18/05/2012 01:51

Es una realidad que los avances en medicina, el alto nivel de control de las enfermedades agudas y por lo tanto  la esperanza de vida que hoy día tenemos han dado lugar a un elevado número de enfermedades crónicas, y que cada vez es mayor, por no decir de la elevada cantidad de pacientes con pluripatologias.

Es evidente, y lo vemos todos los dias en nuestro trabajo, que la prevalencia de la polipatologia aumenta con la edad, pero también hay algunos datos que personalmente me han llamado la atención, en concreto: El hecho de ser mujer con un nivel socioeconómico bajo, y los pacientes que tienen seguro médico público!!. Esto último solo se me ocurre, que los médicos de la sanidad pública se encuentran muy desbordados de trabajo y  no disponen del tiempo necesario para cada paciente. Me gustaría que algún compañero me aclarara esto.

Otro problema que me gustaría comentar es el problema de la polimedicación de los pacientes crónicos, porque parte de la medicación es evidentemente justificada pero también  la hay no justificada como, automedicación, duplicidades, medicación no necesaria, inapropiada, baja utilidad terapéutica,etc, y por tanto la probabilidad de que aparezcan reacciones adversas aumenta con el número de medicamentos tomados,y que muchas de estas reacciones adversas pasan desapercibidas como tal,y en la consulta del médico se pueden considerar como nuevos síntomas de la enfermedad, dolencias o incluso nuevas enfermedades, por tanto se prescriben nuevos fármaco sin caer en la cuenta que con la simple sustitucíon del fármaco o la eliminacón desaparecerian esos síntomas. Es por tanto muy necesaria la revisión sistemática y periódica de la medicación. La información no es un complemento sino que forma parte del tratamiento.

Maria Eugenia Velasco Contreras · 02/08/2013 18:47

Considero que la epidemia de enfermedades crónicas generada por el estilo de "vida moderno" : consumo de alimentos basura- hipercaloricos, de alto indice glucemico, sin nutrientes esenciales como vitaminas y minerales, acompañada del consumo epidémico de drogas legales como tabaco y alcohol, complicado en miles casos con el consumo de drogas ilegales, ha generado en la población mundial el sindrome metabólico y el cáncer en general.

El tratamiento con farmacos poderosamente promovido por los laboratorios del bloque capitalista, han hecho sus millonarias ganancias con la "complicidad" de los expertos especialistas; que para no frustrarse por la falta de respuesta y "control" en la población de las adicciones, la elevación del peso corporal con incremento de la grasa que invade órganos vitales y que causa elevación de la presión arterial,  lipidos, glucosa, acido úrico, mal funcionamiento del sistema inmunologico que culmina en muerte prematura o alta mobilidad por enfermedades cardiovasculares, renales, hepaticas y cáncer. Y que con el uso de medicamentos: antihiperteivos, hipoglucemiantes, hipolipémicos, antiadhesivos plaquetarios, solo por ciertas horas existe control de las "variables" vitales. Nuestro reto como personal de salud capacitado para comprender la "multicausalidad" de las enfermedades crónicas es modificar esta organización de los servicios de salud, basados en el consumo de farmacos y drogas por la población que sirve para activar la economia de los dueños con su dinero en los bancos.  Han dado resultados muy desastrosos para la población atendida bajo este regimen criminal por decir lo menos. Considero que las personas que mantienen su peso adecuado a su estatura, como resultado de tener hábitos de alimentación saludable, práctica de ejercicio fisico diario, y disfrutan de sus vidas sin drogas, pueden tener una vida mayor a los 100 años, y que son ejemplo para la humanidad por ocuparse de cuidar su salud, y con ello la salud de sus seres queridos y de su comunidad. Pero adémas considero que  el conocimiento de ellos sobre lo que significan estos hábitos es bastante bueno. Es un enigma que debemos investigar ¿por que no lo hacen? Incluido el personal de salud ¿he?

ebarranco
Ezequiel Barranco Moreno
04/05/2014 09:55

El abordaje del paciente con polipatología es muy interesante y el libro viene a decir lo que, en términos generales, sabemos que se debe hacer y que sin embargo no se hace, probablemente por diversas causas:

- La falta de interacción etre distintas especialidades, niveles asistenciales y recursos sociales.

- Los programas de atención centrados en el paciente, muy desarrollados teóricamente pero no en la práctica.

- La falta de interés en llevarlos a cabo: Salvo honrosas excepciones (algunos planes asistenciales: Cuidados paliativos, pluripatológicos...), centradas exclusivamente en una patología concreta.

- La falta de sensibilidad en la gestión (veamos los objetivos y criterios de productividad de los distintos hospitales y centros de salud a ver si encontramos de forma habitual referencias a desarrollo de atención integral) y la consiguiente escasez de medios (tiempo y recursos)

- Las diferencias entre sistemas de salud y areas asistenciales (vease la "desaparición" de geriatría en Andalucía, o las diferencias de aención a pacientes terminales en cada área hospitalaria) y la progresiva pérdida de identidad de Cuidados Paliativos, incluidos sin explicación que lo justifique en Medicina Interna, como una sección sin la automoía suficiente para el abordaje integral y homogéneo de la población.

- Los capítulos del libro demiuestran la necesidad de atención integral basada en la persona, su desarrollo es muy claro y contundente y el esfuerzo en su elaboración totalmente admirable, así como el resultado y su edición. Sin embargo ni yo ni los compañeros con los que he hablado teníamos conocimiento del mismo ¿Ha llegado a los destinatarios o interesados?

inmaga60
Inmaculada Angulo Garcia
17/05/2014 08:36

Mi parecer es que como cuando estudiabamos los libros crean unas directrices que son muy loables, pero su puesta en práctica , choca con las políticas sanitarias que arrastramos muchas veces lastres y otras que cambian de un gobierno a otro y no existe una continuidad en su puesta en práctica por los profesionales

Tambien existe a nivel de mi empresa un desencanto sobre todo en los profesionales de que esto no hay quien nos lo cambie ni nos motivan, un ejemplo personal es que cuando inicie mi nueva andadura en primaria me encontre que para hacer un trabajo como era el de la revisión de niño sano por enfermeria mi consulta , o las dos consultas con las que cuenta enfermería carecian de peso, metro, y tallimetro. 

Después de 8 años sigo midiendo a los niños con una cartulina milimetrada, y a los de 15 meses los pesamos o en la báscula de baño que tenemos en la actualidad o en el pesabebes , y muchas veces ni en uno ni en otro sitio es fiable 

Estas deficiencias que se hacen saber a los gestores, como están en sus ámbitos laborales ,no las arreglan pues no las ven un día tras otro. 

Esto hace que un trabajo simple se convierta en un periplo insoslayable. Y así van minando la moral de los profesionales que con ilusión vamos a cursos, nos intentamos actualizar y luego se nos va en estas luchas pírricas la fuerza. 

estrella_ana50
Estrella Rodriguez Ferrer
20/05/2014 19:11

Pienso que es fundamental el tema de la educación y prevención en la población desde el área sanitaria, por todos los profesionales e intervenir en los programas de salud e inculcar a la población en general la educación en habitos de vida saludables ya que hay enfermedades que se convierten en crónicas cuando con un programa de intervención educando al paciente desde temprana edad evitaríamos que se llegara a la cronicidad y evitar asi que se conviertan en pacientes plurimedicados con las consecuencias que ello conlleva.

victoriamyanez
Maria Victoria Martin Yanez
21/05/2014 18:57

Me ha llamado la atencion el parrafo"Además de la edad avanzada, análisis multivariados han demostrado que la obesidad, el hecho de ser mujer con un status socioeconómico bajo, y vivir solo son factores que aumentan de manera significativa la probabilidad de tener tres o más enfermedades crónicas .

Aparte de la relación con el género y la edad avanzada, otro estudio indicó que existía un mayor riesgo de polipatología entre las personas con un nivel de educación bajo, las que tienen seguro médico público y las que viven en una residencia de ancianos ". 

Creo que nuestros gestores y nosotros mismos deberiamos  replantearnos nuestra actuacion ante colectivos tan sensibles como la mujer,residentes en geriatricos y por supuesto los que nos han traido a este curso los cronicos

olgagavin
Olga Gavín Blanco
05/08/2014 21:59

Estoy totalmente de acuerdo con las opiniones anteriormente expuestas. Nos encontramos ante pacientes que presentas múltiples patologías que normalmente son atendidos por múltiples especialistas que indican cuidados en ocasiones inasumibles por el enfermo por su contexto social, en otras ocasiones directamente contradictorias (beba mucha agua del urólogo con el no beba demasiada agua del cardiólogo) y casi siempre polimedicados. La polimedicación a su vez ocasiona más frecuentemente errores, interacciones, falta de adherencia... Por ello, en los tiempos que corren y por los tiempos que correrán es indispensable y fundamental la visión global del médico internista y los modelos de coordinación asistencial entre niveles.

Muchas veces, lo que sucede es que el enfermo bypasea el sistema acudiendo a urgencias porque considera que desde Atención Primaria se le va a derivar demasiado tarde a atención especializada, y encima como son enfermos con múltiples patologías en ocasiones incluso son ingresados directamente desde el propio servicio de Urgencias Hospitalarias generando muchísimo gasto. Sólo con una Atención Primaria potente y una buena coordinación asistencial con Medicina Interna que actuara como consultor y facilitador del segundo nivel asistencial puede realizarse una gestión  más costoefectiva. 

esterita_07
Esther Martin Aurioles
14/09/2014 14:10

Estoy de acuerdo con todo lo expuesto por Ezequiel (mensaje numero 10), el  trabajo realizado es muy interesante. Pero es necesario que toda esta información llegue a más gente y que desde los puestos de gestión se apoye la iniciativa.

La revisión de pacientes polimedicados, el abordaje conjunto de pacientes con enfermedades crónicas, algunas iniciativas de grupos de trabajo en mi Distrito se están llevando a cabo. 

MARIQUILLA

Estoy de acuerdo con las opiniones anteriores y el contenido del libro me parece muy interesante porque actualmente nos encontramos con un gran numero de enfermedades crónicas y con pacientes pluripatológicos. 

La pluripatologia trae consigo un aumento de fármacos y como profesionales sanitarios debemos recordar que cualquier fármaco tiene riesgo de provocar en el paciente efectos secundarios, por lo que no deberian ser recetados si no son completamente necesarios. 

Pienso que la clave está en la promoción y prevención de la población desde temprana edad para conseguir disminuir las cifras de pacientes polimedicados.

Podríamos plantearnos la siguiente pregunta: ¿deberiamos cambiar nuestra visión de la enfermedad crónica y del proceso de envejecimiento y plantearla de otra manera?

Valle
María Valle Serrano Muñoz
27/11/2014 10:59

Estoy de acuerdo con Inmaculada sobre los medios con los que trabajamos. Para completar el tratamiento con éxito, muchas veces es necesaria la intervención del profesional de enfermería quien se encarga de “desmenuzar “ el  tratamiento para que el paciente lo entienda y lo incorpore a su vida diaria, sobre todo cuando se trata de cambiar hábitos. Este proceso de “desmenuzar” e incorporar a la vida diaria  los nuevos hábitos como una costumbre más exige un tiempo de dedicación, un espacio , unos medios y un material educativo de calidad de los que no siempre dispone el personal de enfermería.

De nada sirve un diagnóstico acertado y un tratamiento adecuado si el paciente no ce ciñe a él porque no lo entiende o no está motivado. Junto a los recursos materiales necesarios , se hace imprescindible la formación en comunicación con el paciente, en métodos educativos adecuados y en técnicas de motivación.

peperuin
José Luis Rodríguez Cubas
13/12/2014 22:35

Al hilo de los comentarios anteriores, muy acertados, destacar que :

  1. No puede haber un abordaje correcto de la cronicidad si la tan cacareada e inexistente coordinación  sociosanitaria (intervienes e intersectorial). En Canarias aún no disfrutamos de una historia de salud digital compartida entre Atención Primaria y Hospitalaria, y así la tarea es mucho más ardua. A partir de ahí, estratificar, priorizar y actuar globalmente sobre las personas frágiles es el camino a seguir.
  2. El sistema sanitario actual NO está diseñado para el abordaje de la cronicidad; responde muy bien a la patología aguda, pero no da respuesta al paciente crónico complejo que va a la deriva intervienes siendo objeto de multiplicidad diagnósticas y terapéuticas. Necesitamos una renovación profunda de nuestras agendas asistenciales, en particular en lo referente a Atención Primaria para recibir adecuadamente a la Cronicidad.
  3. Necesitamos referentes que guien el periplo de los pacientes crónicos complejos a través de las duras mareas interniveles ( enfermería gestora de casos, referente hospitalario gestor de casos, refuerzo de la atención domiciliaria y de los soportes hospitalarios a domicilio,etc), que también tengan competencias sobre el sector social y trabajen sobre una única historia sociosanitaria del paciente.
  4. Finalmente, y ya que se ha nombrado mucho antes, resaltar el complejo problema de la polimedicación. En Canarias ya está en marcha un ambicioso programa de abordaje de la polimedicación a través de un módulo único de prescripción independiente que comparten los médicos de Atención Primaria y Atención Hospitalaria. Este módulo da al profesional acceso directo al programa de polimedicados (inicialmente enfocado a los mayores de 65 años con 10 ó más medicamentos en su plan de tratamiento), lo cual le mantiene constantemente actualizado acerca de las variaciones que se produzcan en el mismo desde cualquier nivel de atención sanitaria, a traves de una serie de alertas automáticas  que detectan problemas de seguridad, interacciones, duraciones excesivas y UTB. 
EliaP

Las patologías crónicas son el principal problema de salud para la población y el mayor desafío de los sistemas sanitarios actuales. Para una adecuada respuesta a las necesidades de las personas que padecen enfermedades crónicas, hay que plantearse nuevos retos para la organización sanitaria.

El abordaje a la atención a la cronicidad debe ser multidisciplinar y continuado en los diferentes ámbitos asistenciales (Atención Primaria, Atención Hospitalaria y Atención Sociosanitaria) potenciando su comunicación y coordinación. El reto de la cronicidad pasa por fortalecer la Atención Primaria. 

Se ha de ofrecer una atención sanitaria y social integral e integrada, además de implicar y corresponsabilidad al paciente en la gestión de su propio proceso asistencial.

Las TICs son un apoyo para para este reto.

Entre las estrategias para afrontar la cronicidad debe encaminarse políticas farmacéuticas para el uso adecuado de la medicación, en el creo de vital importancia dar herramientas de ayuda a la desprescripción razonable a los profesionales sanitarios. 

 

franciscovico60
Francisco Vico Ramirez
05/10/2015 08:51

Estoy más cercano a los planteamientos de la doctora Starfield que a los de Wagner sin dejar de valorar la aproximación de éste último.  Sin embargo creo que al final nadie propone un modelo organizativo en países como el nuestro en el que la AP está suficientemente organizada. 

Sostengo que unas agendas que retienen a los profesionales a esperar a que los mismos pacientes consulten por los mismos problemas de manera reiterada y estéril han de ser dinamitadas por más que "beneficien" a muchos.

Porqué si sabemos tanto de un tema no existe voluntad de un cambio real. En los últimos 25 años ninguna modificación ha sido posible. Nadie genera acciones proactivas hacia los pacientes crónicos desde AP. Hemos generados miles de documentos que se aplican poco y desde la consulta no desde los domicilios. En efecto nuestros pacientes desaparecen del radar hasta que vuelven a recaer y no trabajamos con perfiles, listados priorizados con perfiles de riesgo.

Sabemos lo que tenemos que hacer, cómo lo tenemos que hacer y quien lo tiene que hacer pero seguimos cómodamente sentados en nuestros sillones de 8 a 13 h y salimos con mal gesto a hacer los domicilios sólo cuando nos avisan.....

y en este curso tampoco veo que nadie se moje y descienda a la realidad.... 

mjramirez
María José Ramirez Espejo
03/10/2017 17:40
Las enfermedades crónicas son un hecho real que conlleva y que va directamente relacionado con la calidad de vida, ya que en otra época esas enfermedades quizás llevaba a una persona que lo padeciera a la muerte. Sin embargo gracias a los avances muchas de esas enfermedades se han cronificado. No obstante es fundamental la investigación y mejora continua para conseguir la prevención de tales enfermedades y ello sin duda es haciendo hincapié en la necesidad de modificación de los hábitos de vida por unos más saludables, ya que muchas de esas enfermedades tienen relación directa con ello.
crisguitard
mientras no afrontemos el gran reto que supone el tratamiento de las enfermedades crónicas desde todos los prismas requeridos, un manejo adecuado de estos enfermos y de su entorno familiar será difícil. Debemos cambiar la perspectiva de nuestra actuación, evitar medidas innecesarias y garantizarles un abordaje adecuado para asegurar una calidad de vida adecuada hasta el final de la vida.
gematinfil
Gema Martin Marfil
06/07/2019 20:25
Creo que las enfermedades crónicas es una realidad que cada vez está más tratada como un todo, pero desde luego lo primordial es la promoción de la salud ya que todo tratamiento supone efectos secundarios y riesgos. Es complejo abordar en consultas de 5 minutos enfermos pluripatológicos con un abordaje integral por la saturación de la consulta y la falta de tiempo real. Sería más productivo incentivar los buenos hábitos para garantizar mejor calidad de vida en dichos pacientes.
 
 
 
References: Epidemiology Collaborative document